REPROSAIT 4 U

The rectum is the temporary storage area for bowel motions, and makes up the last 20cm or so of the large bowel.

A rectocele occurs when the rectum pushes the back wall of the vagina forward, causing a prominent bulge into the vagina.

Risk factors include difficult childbirth and the use of forceps during delivery, but women who have never had children can also develop rectocele.

The degree of severity varies; for example, in mild cases the rectocele may be felt as a small bulge high inside the vagina while, in severe cases, the bulge may be hanging outside of the vagina. Milder cases can be treated by measures such as management of constipation, Kegel exercises to strengthen the pelvic floor and the insertion of a vaginal pessary to prop up the pelvic organs. Surgery may be needed in severe cases.

Symptoms

The symptoms of rectocele may be vaginal, rectal or both, and can include:

1. A sensation of pressure within the pelvis
2. The feeling that something is falling down or falling out within the pelvis
3. Symptoms are worsened by standing up and eased by lying down
4. Lower abdominal pain
5. Lower back pain
6. A bulging mass felt inside the vagina
7. Vaginal bleeding that’s not related to the menstrual cycle
8. Painful or impossible vaginal intercourse
9. Constipation
10. Problems with passing a bowel motion, since the stool becomes caught in the rectocele
11. The feeling that the bowel isn’t completely emptied after passing a motion
12. Faecal incontinence (sometimes).

Rectovaginal septum explained

The pelvic organs are supported by the pelvic floor muscles. Structures including ligaments and connective tissue help to keep the pelvic organs tethered in place. In women, the front wall of the rectum is situated behind the rear wall of the vagina.
The front wall of the rectum and rear wall of the vagina, and the thin layer of tissue between them, are together called the rectovaginal septum (or wall). This wall can become weak or stretched by pressure such as childbirth or straining while going to the toilet and by ageing. A weak or thinned rectovaginal septum allows the front wall of the rectum to bulge into the vagina.

A range of causes

Some of the events that may weaken or thin the rectovaginal septum and cause a rectocele include:

• Vaginal (normal) childbirth
• Giving birth to multiple babies
• A long and difficult labour
• Assisted delivery during childbirth, including the use of forceps
• Tearing during childbirth, particularly if the tear extended from the vagina to the anus
• Episiotomy (a surgical cut made to enlarge the vaginal opening during childbirth to avoid injury to mother and baby), particularly if the cut extends to the anus
• Hysterectomy
• Pelvic surgery
• Chronic constipation
• Straining to pass bowel motions
• Advancing age, as older women are more prone to rectocele.

Related problems

A rectocele sometimes occurs by itself. In other cases, it may present alongside other abnormalities including:

1. CYSTOCELE - the bladder protrudes into the vagina.
2. ENTEROCELE- the small intestines push down into the vagina.
3. UTERINE PROLAPSE - the cervix and uterus drop down into the vagina and may protrude out of the vaginal opening.
4. VAGINAL PROLAPSE - in cases of severe uterine prolapse, the vagina may slide out of the body too.
5. RECTAL PROLAPSE - the rectum protrudes through the anus.

Diagnosis methods

Rectocele is diagnosed using a number of tests including:

1. Pelvic examination
2. Special x-ray (proctogram or defaecagram).

Treatment options

Generally speaking, a rectocele with no obvious symptoms doesn’t need medical treatment, but it is wise to pay attention to diet and other lifestyle factors that contribute to constipation. Treatment options may include:

1. High fibre diet
2. Fibre supplements
3. At least six to eight glasses of water per day
4. Stool softeners (don’t use laxatives)
5. Instruction on how to help yourself to pass a bowel motion; for example, you may be advised to gently press a finger against the rear wall of the vagina while toileting
6. Don’t strain on the toilet
7. Hormone replacement therapy for postmenopausal women
8. Pelvic floor (‘Kegel’) exercises
9. The insertion of a pessary, which is a ring-like device worn high in the vagina that helps to support the pelvic organs.

Surgery

Surgery may be needed if the rectocele doesn’t respond to other treatments and is causing symptoms. Unfortunately, the rectocele will recur after operation in about 10 per cent of cases. Depending on individual factors, such as the severity of the rectocele and the presence of other prolapsed structures, the operation can be performed in a number of ways, including:

• Through the vagina
• Through the anus
• Through the area between the vagina and anus (perineum)
• Through the abdomen
• In some cases, a combination of surgical techniques may be necessary.

Things to remember

• Some of the causes of a rectocele include vaginal childbirth, hysterectomy, pelvic surgery and chronic constipation.
• A rectocele may occur by itself or present alongside other pelvic abnormalities, such as a prolapsed bladder (cystocele).
• Surgery may be needed if the rectocele doesn’t respond to simpler treatments.